Ординатура / Офтальмология / Английские материалы / Clinical Ophthalmic Echography_Harrie_2008

YS is a 56-year-old Egyptian man who had been struck in the face with the end of a shovel as he stood behind a fellow worker on a construction site. His left eyelids were swollen shut and there was significant bruising that involved the paraocular area and into the upper cheek. He presented to the eye clinic at the local hospital 2 weeks later with resolution of the eyelid edema, but had blurred vision, floaters, and mild discomfort in that eye.

Examination showed vision in the right eye of 20/25 and in the left of 20/60. The intraocular pressure was 15 mm OD and 13 mm OS. Slit-lamp examination showed mild anterior chamber reaction and some vitreous cells in the left eye with an adequate view of the fundus, but a poor view of the inferior temporal periphery because of some residual hemorrhagic debris in that area.

B-scan revealed a vitreous membrane inserting at the 4:30 position with focal thickening of the retinochoroid layer suspicious for an occult rupture (Fig. 350). Vitreoretinal surgery was considered, but was not locally available. The clinical situation was felt to be stable and careful observation was planned. The patient was advised to return in 2 weeks for

FIG. 350. B-scan of vitreous incarceration in occult rupture site (arrow)

reevaluation and referral for surgery if evidence of a traction retinal detachment was seen.

There are often limited therapeutic options in more remote areas of developing countries. Echography can assist in identifying those individuals in whom intervention may be worthwhile.

A 72-year-old native of Vanuatu lived on one of the remote islands. He lost his left eye as a child due to injury and had gradually experienced reduction in the vision in his right eye with a rapid decline over the past several weeks with some discomfort. He heard that a volunteer group from Australia was taking people from his island by sailing vessels to the capital city of Port Villa on the island of Efate for the treatment of eye problems. He and many of the inhabitants had never left their island and were afraid to make such a journey over open ocean to be treated by strangers. However, his vision was almost gone and he felt he had no choice but to go.

Examination showed vision in the right eye of light perception and a phthisical left eye. There was 2 to 3+ corneal edema with a hazy view of the anterior chamber. There appeared to be a dense cataractous lens and no view of the fundus. The intraocular pressure was measured to be 50 mm by Schiotz tonometry.

Echography using an immersion technique revealed a large cataractous lens measuring over 6 mm with a shallow anterior chamber (Fig. 351). The posterior segment appeared unremarkable. The diagnosis of an intumescent lens with secondary angle closure was made and he underwent lens removal by extracapsular extraction the next day. His pressure was measured at 20 mm and he could see at the 20/200 level. The plan was to supply him with a pair of donated +12.0 aphakic spectacles. The optic

FIG. 351. B-scan of intumescent lens (arrow)

nerve showed 8/10 cupping and he had moderate constriction of his visual field on confrontation testing. He was very happy with the result and returned to his island. He encouraged his visually impaired friends to make the journey to the capital the following year when the volunteer team would return.

Diabetes is often undetected or undertreated in many less advanced areas of the world. The ocular complications of this disease include cataract formation and vitreous hemorrhage, which can obscure the fundus. Echography allows visualization of the posterior pole and the patient can be advised on the prognosis for visual recovery.

HA is a 32-year-old Peruvian woman who had been diagnosed with diabetes and started on insulin after several years of excessive thirst, frequency of urination, and spontaneous weight loss. She had never had an eye exam. She stated that her left eye had become quite blurry over several weeks and she saw many tiny spots.

Examination found vision in the right eye of 20/40 and the left eye of 20/200. There was a questionable afferent pupil defect in the left eye. Slit-lamp examination was normal and intraocular pressures measured 13 mm in both eyes. The right fundus examination showed moderate proliferative diabetic retinopathy with dot and blot hemorrhages and several foci of intraretinal vascular abnormalities. The optic disc was documented to be covered by greater than 50% neovascularization. The left fundus could not be visualized due to vitreous opacities.

Echography of the left eye revealed 3+ pointlike vitreous opacities consistent with moderate subhyaloid hemorrhage (Fig. 352). The retina was attached and no areas of vitreoretinal traction could be identified. She was instructed to minimize heavy lifting and to elevate her head at night when sleeping.

A portable laser had been donated to the clinic and panretinal photocoagulation was applied to the right eye. She was instructed to return in a month to institute laser treatment in the left eye with the anticipation that the hemorrhage would clear enough to allow some laser treatment. She was informed that there was a good chance of visual improvement once the blood was gone from the eye.

Eyes with a history of trauma are sometimes subject to increased intraocular pressure with resultant optic nerve damage. The B-scan can be

FIG. 352. Top: A-scan of vitreous hemorrhage (arrow). Bottom: B-scan of subhyaloid hemorrhage (arrow)

helpful in detecting optic nerve cupping when it is moderately severe (greater than 0.7 cup-to-disc ratio). It is helpful to view the nerve head in different probe positions (vertical, horizontal, and longitudinal) to find which best displays the optic cup.

A 52-year-old Ethiopian woman gave a vague history of some sort of injury to her left eye several years ago. She had intermittent episodes of pain in this eye and the vision had gradually dropped to light perception. Examination found vision in the right eye of 20/30 and in the left of bare light perception. Her intraocular pressure was difficult to measure in the left eye because of corneal edema and scarring. This prevented a view of the fundus.

B-scan with a horizontal axial view showed marked cupping of the optic nerve consistent with advanced glaucomatous nerve damage (Fig. 353). She was informed that there was no hope for vision in that eye.

Intraocular tumors may present in late stages with severe morbidity. Some intraocular tumors have a different incidence in developing countries than those in the Western nations. Malignant melanoma is the most common intraocular tumor in Caucasian races and is rare in people of darker skin pigmentation. Poorer areas of the world have a higher rate of ocular invasion by metastatic and secondary neoplasms due to failure to treat the primary tumors at early stages when their spread can be

FIG. 353. B-scan of advanced cupping of the optic nerve (arrow)

more readily controlled. Retinoblastoma is the most common intraocular tumor of children throughout the world, but it presents in more advanced stages in less technologically developed areas.

TY is a 2-year-old Bolivian child who was noted by her parents to progressively cross her eyes since she was 6 months old. A local health station nurse told them that she would “grow out of it.” Her left eye later became red much of the time and the “pupil began to appear a different color than the other eye.” She was seen at the local clinic and the parents were given some eye drops for infection and told to bring her back if things got worse.

She was brought into a screening clinic set up by a group of volunteer ophthalmologists from the United States. Her left eye had an esotropia of 50 prism diopters and would not fix on a picture target. The pupil had a white reflex and she was suspected to harbor an intraocular mass.

Echography of the right eye revealed a large mass lesion that filled most of the globe and calcium deposits were detected on A- and B-scan (Fig. 354). A small peripheral calcified mass was noted in the temporal periphery of the left eye (Figs. 355 and 356). The diagnosis of a bilateral retinoblastoma was made and the child was scheduled for enucleation of the right eye with the intent to remove as much of the optic nerve as possible. MRI imaging was not available to evaluate the nerve or CNS for invasion by tumor. A-scan measurements of the optic nerve were performed and were within normal limits, but microscopic invasion by tumor could not be ruled out. She was referred to the oncology center of a government hospital for chemotherapy in an attempt to preserve the left eye. She was told to return in 6 months for repeat clinical examination and ultrasound of the left eye to evaluate the status of the tumor.

FIG. 354. Top: A-scan of large retinoblastoma (arrow). Bottom: B-scan of tumor (first arrow) with scleral and orbital shadowing (second arrow)

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FIG. 355. A-scan of small retinoblastoma (arrow).

There is a long differential diagnosis of lesions besides retinoblastoma that can cause leukocoria. Several of the more important ones can only be accurately diagnosed by echography. The correct

Case Study 199. Retinoblastoma

FIG. 356. B-scan of tumor (arrow)

diagnosis can direct appropriate treatment and spare a child unnecessary surgery in such cases.

MA is an 18-month-old Honduran male who was noted to have a white pupil reflex in the right eye when a photograph was taken by a visiting relative. He was taken to the local clinic where a probable tumor in the eye was diagnosed and he was referred to the eye department of a government hospital in the capital city, 100 miles away.

He was seen in the eye clinic and the diagnosis of retinoblastoma was made and the child was scheduled for enucleation the next day by one of the ophthalmology residents. A visiting team from an international volunteer group was asked to see the child just prior to surgery. Echography revealed a retrolental opacity with a moderate stalk going back to the optic disc (Fig. 357). The diagnosis of persistent hyperplastic primary vitreous (PHPV) was made and it was suggested that enucleation be cancelled and a lensectomy/vitrectomy be performed instead. The parents were told that this eye would never see well, but without surgery it would probably become blind and painful and have to be removed.

FIG. 357. B-scan of persistent hyperplastic primary vitreous with stalk (arrow)

The limited clinical signs in orbital disease make it difficult to be certain about a specific diagnosis. Often only a long differential diagnosis is possible. Patients may present in advanced stages of orbital disease. Treatment options are usually limited based on what is locally available, such as basic antibiotics, prednisone, and topical beta blockers.

A 34-year-old Indonesian man had a 2-year history of prominence, redness, and irritation of his right eye. He had been treated with prednisone during this time with doses varying from 80 mg a day initially to 20 mg when the process seemed less severe. He had not been evaluated for osteoporosis, ulcers of the stomach, tuberculosis, or diabetes during this time. He had a striking Cushinoid appearance to his facies. Ocular examination showed exophthalmometry measurements of 25 mm OD and 21 mm OS. There was moderate conjunctival injection and chemosis of the right eye. His vision was 20/40 OD and 20/25 OS with a 2+ posterior subcapsular cataract noted on the right. Intraocular pressure measured 21 mm OD and 20 mm OS. Fundus examination showed a cup to disc ratio of 5/10 OD and 4/10 OS. Various ophthalmology residents had followed him in the clinic over the 2-year period with the diagnosis of orbital pseudotumor. A plain film skull x-ray had been obtained at one time that was interpreted as normal by the

up. This patient was brought in for echographic examination. The A-scan revealed marked thickening of all of the extraocular muscles bilaterally with medium-to-high irregular reflectivity (Fig. 358). B-scan revealed abnormal thickening of the superior rectus/levator complex bilaterally.

FIG. 358. A-scan of thickened extraocular muscle (arrows)

The diagnosis of Graves’ disease was made and the patient was sent for thyroid testing. His basic thyrotropin level was normal but antithyroid antibody testing was not done. He was advised to begin tapering his prednisone with the goal to lower the dose to physiologic levels within 3 months. He was given the treatment options of orbital radiation or an injection of kenalog into the orbital tissue.

There are often very limited resources to address paraocular and orbital problems. CT and MRI scanners may be found in the major cities with limited access by much of the population because of expense and travel distance. Plain film x-rays are more readily available but are of limited value in orbital diagnosis.

A 41-year-old man was seen as part of the ultra- sound-training course given by a visiting volunteer team to the university hospital in Jakarta, Indonesia. He gave a history of “a big right eye with some aching for several weeks.” Examination showed 8 mm of proptosis of that eye with 3+ conjunctival injection and chemosis. The vision was measured at 20/70 OD and 20/25 OS. The left eye appeared normal on clinical examination. A plain film x-ray of the orbits was read as normal. He was diagnosed with an orbital tumor and was in the process of being referred to another city for orbital biopsy.

FIG. 359. A-scan of orbital pseudotumor (arrows)

FIG. 360. B-scan of lesion (arrow)

Echography revealed low reflective thickening of several extraocular muscles, increased subtenon’s lucency, and a well-outlined low reflective lesion in the mid-orbit (Figs. 359 and 360). These findings were consistent with orbital pseudotumor and high-dose steroids were started after a chest x-ray and blood glucose tests were performed. He responded with rapid improvement in the proptosis and inflammatory signs.

Inflammatory conditions of the orbital and periorbital area are often not treated by antiinflammatory medications in the early stages and can progress to painfully debilitating problems.

A 43-year-old Mongolian woman who had intermittent pain and swelling around her left eye for over a year. The symptoms had recently increased to the point that she was constantly in pain. She slept poorly at night and was not able to perform her household and childcare chores during the day. She had taken aspirin intermittently without relief of her symptoms. She presented to the government hospital outpatient clinic and was given a supply of ibuprofen. This lessened her pain somewhat, but she was generally incapacitated and sought help at a facility in another city. Examination in the eye department showed marked temporal conjunctival and episcleral injection of the left eye with mild lid swelling. The vision was reduced to 20/60 in that eye while the right eye was measured at 20/30. She had a 10-prism diopter left esotropia with increased pain on looking to the left. Slit-lamp examination of the left eye showed a clear cornea and a deep anterior chamber with mild flare but no cells. Fundus examination showed a clear vitreous cavity and some possible thickening of the temporal retinochoroidal layer.

Echography revealed moderate thickening of the sclera and some increased lucency of subtenon’s space. The left lateral rectus muscle was thickened near its attachment to the globe and posteriorly (Fig. 361). The diagnosis of a lateral rectus myositis with adjacent scleritis was made and she was started on high-dose oral steroids with rapid resolution of her symptoms.

Some orbital problems, such as cystic lesions, are amenable to simple surgical incision and drainage. These procedures often do not require the technology and trained personnel as would be necessary for more complex procedures. Ultrasound

FIG. 361. Top: A-scan of thickened sclera (first arrow) and muscle belly (second and third arrows). Bottom: B-scan of tendon (arrow)

may be useful in such situations both by enabling a correct diagnosis and by guiding needle aspiration of the lesion.